Interventions for improving employment outcomes for persons with autism spectrum disorders: A systematic review update

Abstract Background The incidence of autism spectrum disorders (ASD) is on the rise. Currently, 1 in 59 children are identified with ASD in the United States. ASD refers to a range of neurological disorders that involve some degree of difficulty with communication and interpersonal relationships. The range of the spectrum for autism disorders is wide with those at the higher functioning end often able to lead relatively independent lives and complete academic programs even while demonstrating social awkwardness. Those at the lower functioning end of the autism spectrum often demonstrate physical limitations, may lack speech, and have the inability to relate socially with others. As persons with ASD age, options such as employment become increasingly important as a consideration for long‐term personal planning and quality of life. While many challenges exist for persons with ASD in obtaining and maintaining employment, some research shows that, with effective behavioral and social interventions, employment can occur. About 37% of individuals with ASD report having been employed for 12 months or more, 4 years after exiting high school. However, several studies show that individuals with ASD are more likely to lose their employment for behavioral and social interaction problems rather than their inability to perform assigned work tasks. Although Westbrook et al. (2012a, 2013, 2015) have reviewed the literature on interventions targeting employment for individuals with ASD, this review is outdated and does not account for recent developments in the field. Objectives The objective of this review is to determine the effectiveness of employment interventions in securing and maintaining employment for adults and transition‐age youth with ASD, updating two reviews by Westbrook et al. (2012a, 2013). Search Methods The comprehensive search strategy used to identify relevant studies included a review of 28 relevant electronic databases. Search terminology for each of the electronic databases was developed from available database thesauri. Appropriate synonyms were used to maximize the database search output. Several international databases were included among the 28 databases searched. In addition, the authors identified and reviewed gray literature through analysis of reference lists of relevant studies. Unpublished dissertations and theses were also identified through database searches. The programs of conferences held by associations and organizations relevant to ASD and employment were also searched. In sum, the search strategy replicated and expanded the prior search methods used by Westbrook et al. (2012a, 2013). Selection Criteria Selection criteria consisted of an intervention evaluation using a randomized controlled trial or quasi‐experimental design, an employment outcome, and a population of individuals with ASD. Data Collection and Analysis We updated the search from Westbrook et al., replicating and broadening the information retrieval processes. Our wide array of sources included electronic databases, gray literature, and conference and organization websites. Once all potentially relevant studies were located, pairs of coders evaluated the relevance of each title and abstract. Among the studies deemed potentially relevant, 278 were subjected to full‐text retrieval and screening by pairs of coders. Because many intervention studies did not include employment outcomes, only three studies met our inclusion criteria. Given the small number of included studies, meta‐analytic procedures were not used; rather, we opted to use more narrative and descriptive analysis to summarize the available evidence, including an assessment of risk of bias. Results The systematic review update identified three studies that evaluated employment outcomes for interventions for individuals with ASD. All three studies identified in the review suggest that vocation‐focused programs may have positive impacts on the employment outcomes for individuals with ASD. Wehman et al. indicated that participants in Project SEARCH had higher employment rates than control participants at both 9‐month and 1‐year follow‐up time points. Adding autism spectrum disorder supports, Project SEARCH in Wehman et al.'s study also demonstrated higher employment rates for treatment participants than control participants at postgraduation, 3‐month follow‐up, and 12‐month follow‐up. Smith et al. found that virtual reality job interview training was able to increase the number of job offers treatment participants received compared to control participants. Authors' Conclusions Given that prior reviews did not identify interventions with actual employment outcomes, the more recent emergence of evaluations of such programs is encouraging. This suggests that there is a growing body of evidence regarding interventions to enhance the employment outcomes for individuals with ASD but also greater need to conduct rigorous trials of vocation‐based interventions for individuals with ASD that measure employment outcomes.

Search Methods: The comprehensive search strategy used to identify relevant studies included a review of 28 relevant electronic databases. Search terminology for each of the electronic databases was developed from available database thesauri. Appropriate synonyms were used to maximize the database search output.
Several international databases were included among the 28 databases searched. In addition, the authors identified and reviewed gray literature through analysis of reference lists of relevant studies. Unpublished dissertations and theses were also identified through database searches. The programs of conferences held by associations and organizations relevant to ASD and employment were also searched. In sum, the search strategy replicated and expanded the prior search methods used by Westbrook et al. (2012aWestbrook et al. ( , 2013.
Selection Criteria: Selection criteria consisted of an intervention evaluation using a randomized controlled trial or quasi-experimental design, an employment outcome, and a population of individuals with ASD.
Data Collection and Analysis: We updated the search from Westbrook et al., re-plicating and broadening the information retrieval processes. Our wide array of sources included electronic databases, gray literature, and conference and organization websites. Once all potentially relevant studies were located, pairs of coders evaluated the relevance of each title and abstract. Among the studies deemed potentially relevant, 278 were subjected to full-text retrieval and screening by pairs of coders. Because many intervention studies did not include employment outcomes, only three studies met our inclusion criteria. Given the small number of included studies, meta-analytic procedures were not used; rather, we opted to use more narrative and descriptive analysis to summarize the available evidence, including an assessment of risk of bias.
Results: The systematic review update identified three studies that evaluated employment outcomes for interventions for individuals with ASD. All three studies identified in the review suggest that vocation-focused programs may have positive impacts on the employment outcomes for individuals with ASD. Wehman et al. in-dicated that participants in Project SEARCH had higher employment rates than control participants at both 9-month and 1-year follow-up time points. Adding autism spectrum disorder supports, Project SEARCH in Wehman et al.'s study also demonstrated higher employment rates for treatment participants than control participants at postgraduation, 3-month follow-up, and 12-month follow-up. Smith et al. found that virtual reality job interview training was able to increase the number of job offers treatment participants received compared to control participants.
Authors' Conclusions: Given that prior reviews did not identify interventions with actual employment outcomes, the more recent emergence of evaluations of such programs is encouraging. This suggests that there is a growing body of evidence regarding interventions to enhance the employment outcomes for individuals with ASD but also greater need to conduct rigorous trials of vocation-based interventions for individuals with ASD that measure employment outcomes. 1 | BACKGROUND 1.1 | The problem, condition or issue

| Background
According to the Centers for Disease Control and Prevention (CDC), the incidence rate of autism has increased over the past two decades to 1 in 59 children currently being identified with autism spectrum disorder (Baio et al., 2018). Internationally, autism spectrum disorders (ASD) prevalence is most recently reported at one in 160 children; however, this figure likely represents a significant underestimate (World Health Organization, 2019). Although individuals with ASD are capable of achieving academic and vocational success when provided with accommodations and support, outcomes for this group remain dire in terms of adult outcomes in employment and independent living (Roux et al., 2017;Wehman et al., 2018).
ASD refers to a range of neurological disorders that involve some degree of difficulty with communication and interpersonal relationships, as well as obsessive and repetitive behaviors. ASD occurs in all racial, ethnic, and socioeconomic groups. There is a wide range of effects demonstrated across the spectrum. Those at the lower functioning end of the spectrum often demonstrate physical limitations and may not be able to speak or relate socially to others. Those at the higher functioning end of the spectrum are often able to lead relatively independent lives, graduate from academic institutions, but may also be awkward in their social interactions and have difficulty developing friendships. The critical gap represented from the high to the low end of the spectrum dramatically affects employmentrelated skills, abilities, and behaviors (CDC, 2011).
Given the increase of ASD prevalence and the number of students with ASD exiting public school settings, attention is increasingly focused on potential employment outcomes for individuals with ASD. Individuals without severe disabilities are eight times more likely to be employed than individuals with very severe disabilities (National Organization on Disability, 2000). Individuals with ASD are among those least likely to be employed (Dew & Alan, 2007;Roux et al., 2017); only 14%-15% of individuals diagnosed with ASD in the United States gained employment (Cameto et al., 2003;Roux et al., 2017).
Although economic conditions and employer attitudes affect employment opportunities, employment outcomes for individuals with ASD can be improved by providing social, behavioral, and work supports specific to individuals with ASD (Schaller & Yang, 2005;. Several studies have indicated that individuals with ASD are more likely to lose their employment for behavioral and social interaction reasons rather than their inability to perform work tasks (Bury et al., 2020;Dew & Alan, 2007;Hurlbutt & Chalmers, 2004;Solomon, 2020;Unger, 1999;Wilczynski et al., 2013). Conversely, specific employer practices-sometimes referred to as demand side strategies-have been linked to improved outcomes for employees with autism such as collegial understanding, positive work environment, and provision of accommodations (Chan et al., 2010;Hayward et al., 2019). Employment support service providers must often provide social and behavioral interventions along with other supports to effectively facilitate obtaining and maintaining employment for individuals with ASD .
However, relatively few employment support service providers including state vocational rehabilitation counselors have an in-depth understanding of services that are associated with developing successful employment outcomes for individuals with ASD (Dew & Alan, 2007). Social skills and behavioral interventions designed specifically for workplace settings have received increased attention in the research literature as a means of addressing this barrier to employment for individuals with ASD (Gorenstein et al., 2020).
Each state in the United States has at least one state agency that is charged with the provision of vocational rehabilitation services to facilitate employment outcomes for eligible individuals with disabilities. Data accumulated through the national network of state vocational rehabilitation agencies suggest that few individuals with autism requested services. Of the individuals who did request services, few were successfully employed as an outcome of the service.
However, in its latest report, the National Vocational Rehabilitation Service System indicated that in the 2007 fiscal year, it provided services that successfully placed 1774 individuals with ASD into employment situations that continued for 90 or more days (Rehabilitation Services Administration, 2009).

| The intervention
Interventions designed to improve the employment outcomes for individuals with ASD are varied and multifaceted. Interventions can be broadly categorized as aiming to improve access to employment or success in their employment settings, or both within a comprehensive intervention package such as supported employment or customized employment (Baker-Ericzeń et al., 2018;Smith et al., 2019;Wehman et al., 2018). Across the developmental spectrum, these interventions may target individuals ranging from those transitioning from secondary or postsecondary schooling to the workforce or individuals maintaining their employment status. Programs are often government-funded and provided in conjunction with vocational rehabilitation efforts targeted toward individuals with disabilities.

| How the intervention might work
Employment-related interventions for individuals with ASD can function in different ways. For instance, several employment interventions for individuals with autism include job development services such as job searching, application preparation, interview skills, and job negotiation (Wehman et al., 2018). As individuals with ASD may possess varying levels of social competencies, interventions that enhance social skills can be particularly effective for job-related activities such as interviewing and interpersonal interactions with other employees (Grob et al., 2019). Although many individuals with autism are currently served in segregated prevocational settings, previous research has indicated that individuals with previous experience in these segregated settings are actually less likely to eventually gain competitive integrated employment . In addition to job development services, another set of interventions often targets work-related skills such as specific job training tasks that may help individuals with ASD maintain their employment through on-the-job training and long-term support (Schall et al., 2020).
Thus, we hypothesize that the intervention might work to address job development before employment or on-the-job skills and thus improve gainful employment outcomes.

| Why it is important to do the review
This current systematic review is an update to two prior Campbell reviews on this topic, one focused on employment-related interventions for adults (Westbrook et al., 2012a) and the other for youth (Westbrook et al., 2013). Thus, research has been conducted in the area of autism and employment, including prior systematic reviews.
However, the landscape of evidence has changed since these systematic reviews have been conducted, and an updated systematic review on the effectiveness of adult employment assistance interventions for individuals with ASD would not only demonstrate the extent and magnitude of more recent interventions' effects, but also provide ideas for further research that can inform implementation and refinement of related employment-focused programs.
Additionally, several literature reviews have been published in the peer-reviewed literature related to the employment-related interventions for individuals with ASD (e.g., Bennett & Dukes, 2013Rashid et al., 2018;Schall et al., 2020). These recent reviews have provided important and specific findings related to such topics as the employment of individuals with ASD through K-12 to work transition supports (Bennett & Dukes, 2013), the economic costs and benefits of employing individuals with ASD , common challenges and related strategies , and employer practice interventions (Rashid et al., 2018). Likewise, Schall et al. (2020) incorporated a scoping review methodology designed to provide a broader review of related interventions to promote the employment of individuals with ASD. Thus, there is a need for an updated systematic review directly focused on the effectiveness of adult employment assistance interventions for individuals with ASD.
This review intends to identify and describe the effectiveness of behavioral and social interventions that prepare individuals with ASD for employment. In addition, the review intends to serve as guidance for planners of transition and adult programs and as an indicator of how further research would be beneficial.
More needs to be known about the effectiveness of strategies that are successful in supporting the transition of youth and adults with ASD into employment settings. As the population of persons with ASD grows, more demands and expectations will center on schools and vocational support agencies to effectively facilitate their transition into appropriate work and community living settings. Although prior reviews on this topic have emerged since the Westbrook et al. (2012aWestbrook et al. ( , 2013 reviews, a focus on the best-quality evidence and on specific employment outcomes is still needed (e.g., Hedley et al., 2017).

| OBJECTIVES
To determine the effectiveness of employment assistance in securing and maintaining employment for adults and transition-age youth with ASD.

| Criteria for considering studies for this review
A two-stage process was used to determine inclusion or exclusion of studies: (1) title and abstract stage and (2) full-text stage.
3.1.1 | Title and abstract stage With Endnote software, two coders independently assessed and selected for advancement to the next stage of inclusion if titles and abstracts met at least one of the two following criteria:

Participants
The participant sample of study included individuals of any age with a diagnosis of ASD.

Intervention
The focus of the study intervention centered on the topic of employment. The types of employment included were competitive, supported, or integrated employment. Studies in which the experimental groups assigned to sheltered work or nonintegrated work interventions were excluded from the review due to not providing the integrated or mainstream format of employment. Studies that reported effect sizes were included in the review. If these criteria were not clear from the title or abstract, the study was advanced for retrieval of the full text to determine eligibility.

Full-text stage
Full-texts of studies from all citations/abstracts advanced from Stage 1 were retrieved for a final determination of inclusion in the review and analysis. All of the following criteria were required for each study to be included in the review and analysis. Two coders independently assessed study inclusion at this stage.

Research design
Studies used an experimental or randomized controlled trial (RCT) design or quasi-experimental design to report the effects of the intervention.

Participants
The recipients of the intervention were individuals of any age with an ASD and were voluntarily seeking assistance in obtaining employment. Study participants with ASD eligible for inclusion were individuals with Asperger syndrome, autism, Rhett syndrome, childhood disintegrative disorder, or pervasive developmental disorder-not otherwise specified, as defined in the DSM-IV-TR and diagnosed by an appropriate professional. Participants not employed at the time of the study intervention were the focus of this review.
Reviewers did not exclude studies in which the participant pool included both participants who had an employment history and those who did not. Individuals who were employed before an intervention study were not excluded in this review. Study participants with ASD and other secondary disabilities were included; however, study participants with sole disabilities such as mental retardation, schizophrenia, attention deficits, or other nonautism related conditions were not included.

Intervention
The interventions were required to provide adult employment assistance intended to produce employment outcomes for individuals with ASD.
The interventions needed to address social, behavioral, and/or cognitive dimensions related to the acquisition and maintenance of employment among the study participants. The interventions also needed to involve relatively specific and structured experiences designed to support employment placement: for example, providing guidance in completion of applications, resumes, and engaging in interviews; shaping of work skills and appropriate employment setting social skills; employment site supports; designing of jobs/tasks around the expressed needs and desires of participants; teaching of work-related communication skills; or working directly with employers in the structuring of work and work setting features for individuals with ASD. Employment assistance interventions of any duration were included providing that the study authors supplied an adequate description.

Outcome measures
Eligible outcomes included subsequent attainment of an employment placement and specific data about the duration and/or retention of that placement must have been provided. Gainful employment included competitive, integrated, or supported employment. Sheltered work or nonintegrated work was not considered as an outcome measure for this review. Employment encompassed full or part-time placements.

Publication status
Published and unpublished studies were eligible for inclusion in the evidence pool.

Country of origin and language of publication
Studies that were conducted in any country were eligible. We did not exclude studies reported in languages other than English. Although we did not specifically search for non-English literature, we did search selected international databases. A translator assisted the reviewers to determine whether non-English studies that were retrieved should be included in the full-text review. Specifically, a few articles in Japanese were reviewed for relevance but ultimately excluded when they did not satisfy exclusion criteria.

| Electronic searches
We searched within a large number of electronic databases using search terms from domains associated with ASD, employment, and intervention terminology. Due to the combining of the Westbrook et al. (2012aWestbrook et al. ( , 2013 systematic reviews, we did not place any age-related terms in our search strategy. In addition, we searched for our articles after 2008, the most

| Selection of studies
Studies were screened for inclusion/exclusion decisions at two stages, Stage 1: citation and abstract and Stage 2: full-text. The same two coders served as independent reviewers at both stages. A third party was not needed to resolve a coding value difference.

| Citation and abstract stage
At Stage 1, the decision for advancing the retrieved citations and abstracts in Endnote to the full-text stage retrieval was made independently by both reviewers based on meeting two items from a and b of the following questions or a designation by a reviewer of "unsure" If the reviewers were "unsure," the citation/abstract was advanced to the full-text stage for a final inclusion decision. Inter-rater reliability was tested on a sample of 25 studies at this stage and was found to be 95%. Coding differences were resolved through discussion between pairs of reviewers.

| Full-text level
At the full-text Stage 2 level, full texts of all citations advanced from Stage 1 were obtained and coded for an inclusion/exclusion decision.
Two reviewers for each study independently decided whether to include the retrieved full-text studies in the final analyses. An inclusion decision for advancement to the coding stage of the process required that a study met all the criteria presented earlier. When multiple studies used the same sample or outcome data, the study providing the most complete information focusing on our desired intervention outcome was selected for inclusion. Inter-rater reliability was established before initiating coding activities, minimizing coding disagreements. At the Full-Text Stage 2 level, the two reviewers recorded all excluded studies and the reason for exclusion independently. The two reviewers resolved their differences through discussion until they came to agreement.

| Data extraction and management
Data that were extracted and coded from the primary studies included: publication source, subject characteristics, sample source, employment setting, intervention characteristics, type of employment, and outcome measurement. See Supporting Information Appendix A for a copy of the coding form.
Coding was completed by two independent coders with an Excel-based coding sheet. Any discrepancies were resolved by a third-party author.

| Assessment of risk of bias in included studies
Included studies were coded by two independent reviewers for methodological quality addressing dimensions that included: • Unit of analysis (e.g., intention to treat, test only, treated) • Attrition from pretest to posttest • Fidelity of implementation (e.g., following replicable program of intervention)

• Blinding of assessors/interventionists
In addition, an evaluation of the potential risk of bias of all included studies was conducted using "Risk of Bias" procedures developed by Higgins and Green (2011) in which studies are evaluated across five sources of potential bias. A report of this analysis is provided in Section 4.

| Measures of treatment effect
The magnitude of the intervention effects was calculated as either a Cohen's d or an odds ratio (OR), depending on the nature of the outcome. If the outcome was continuous (i.e., amount of wages earned), the effect size was calculated as a Cohen's d, or standardized mean difference. When the outcome was dichotomous (i.e., employed or not), then we calculated ORs for effect sizes. Effect sizes were calculated directly from reported means and standard deviations or percentages for the experimental and control groups for studies that reported such statistics along with the sample sizes.

| Unit of analysis issues
When studies reported multiple outcomes for the same group comparison, such as various timepoints, there are dependency issues that may arise when synthesizing effect sizes together. Because we did not statistically integrate any effects together, but rather discussed narratively the individual effects, issues of dependency do not impact the results of our summary.

| Dealing with missing data
After using our coding guide to extract data, there were instances of missing data where studies did not report complete information covered in the coding guide. Because effect size data were complete, and no moderator analyses were conducted, we did not attempt to request information from authors or conduct any imputation techniques.
3.3.9 | Assessment of heterogeneity Because of our narrative approach to describe interventions effects given the small number of included studies, we did not perform a formal assessment of heterogeneity. Due to the small number of studies, we also did not explore any selection or reporting biases.

| Data synthesis
Due to the small number of included studies, we opted to describe the findings of the included studies narratively. We conducted no quantitative data synthesis of the effects.

| Subgroup analysis and investigation of heterogeneity
We did not conduct any subgroup or investigations of heterogeneity through moderator tests.

| Sensitivity analysis
We did not conduct any sensitivity analyses.

| Included studies
This section narratively summarizes the included studies and their characteristics such as research design, sample sizes, setting, recruitment, participants, interventions, and outcomes. Note that the studies will be referred to by the last name of the first author and the year of the publication.

| Research design
All three included studies used RCT designs Wehman et al., , 2017. Two of the three studies used a random number generator to assign individual participants to treatment or control groups (Wehman et al., , 2017. No studies used stratification or wait-listed control groups as part of their design. All three studies included data from follow-up points.

| Sample sizes
The unique number of participants from both treatments and comparison groups across the three included studies was 108. The average sample size per study was 36 participants (T: 23.3 participants; C: 12.7 participants).

| Setting and recruitment
In two of the three studies, local education agencies (LEAs) assisted in the recruitment of eligible participants meeting inclusion criteria (Wehman et al., , 2017. Recruitment in the remaining study was conducted through advertisements at local universities, community-based service providers and support groups, and online support groups .
The settings for the treatment groups in Wehman et al. ( , 2017 were located at community-based employment sites at hospitals within a single region. The control groups for these studies attended high school and continued their normal course of study for the duration of the academic year. The setting in the third study was private offices for the intervention and a clinical space for the assessment phase .

Disability type
None of the three studies included specific diagnostic disability assessment as part of their design, instead accepting previous medical and educational diagnoses. Since all three studies were conducted shortly after publication of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, previously used differential ASD labels were reported in each study. One study reported that all participants had diagnoses of high-functioning autism . Two other studies reported specific autism diagnoses with  reporting treatment group composed of 62.5% autism; 25% PDD-NOS; 12.15% Asperger's, and control group of 81% autism; 12.15% PDD-NOS; 6.3% Asperger's. Wehman et al. (2017) reported that the treatment group consisted of 70.9% autism; 19.4% PDD-NOS; 9.7% Asperger's syndrome, and the control group 72.2% autism; 33.3% PDD-NOS; 5.5% Asperger's syndrome.

Age and ethnicity
All studies reported both the age and race/ethnicity of participants in both treatment and control groups. Mean ages of participants ranged from 19.13 years  to 25.0 years . Of the total participants included in this review, 50% reported race/ethnicity as White, followed by 42% African American, 4% Latino, and 3% Asian.

Education level and socioeconomic status
Two of the three studies used participants who were in their last year of high school (Wehman et al., , 2017. Smith et al. (2015) reported parental education, but not participant education level.
None of the studies mentioned socioeconomic status, though one study included information about the number of parents in the household and parents' occupation type (Wehman et al., 2017). In the third study, Virtual Reality Job Interview Training (VR-JIT) was used , which consisted of a digital simulation of a job interview with a human resources representative from a department store. While the application can be accessed through a typical computer, in the study, participants accessed it using wearable virtual reality headsets.

Outcomes
Employment status was the primary outcome measure of each of the three included studies Wehman et al., , 2017. Smith et al. (2015) also included outcome measures specific to job searching and interviewing such as time spent looking for a job and number of interviews completed.

| Excluded studies
Studies were excluded on the following bases: (1) did not include an employment outcome; (2) did not assess the impact of an intervention; (3) did not include a sample of individuals with ASD.

| Characteristics and risk of bias in included studies
In the following sections, we describe the characters of the three included studies, outlining the method, setting, participant, intervention, and outcome. We also include the risk of bias assessment.

| Synthesis of results
Due to the few studies included in the update, we narratively describe the effects of the three included studies. Two studies (Wehman et al., , 2017  Together, these three included studies provide promising evidence for the effectiveness of programs similar to Project SEARCH and virtual reality job interviewing to enhance employment for individuals with ASD.

| Summary of main results
The systematic review update identified three studies that evaluated employment outcomes for interventions for individuals with ASD. Given that prior reviews (Westbrook et al., 2012a(Westbrook et al., , 2013 did not identify interventions with actual employment outcomes, the more recent emergence of evaluations of such programs is encouraging. This suggests that there is a growing body of evidence regarding interventions to enhance the employment outcomes for individuals with ASD. All three studies identified in the review suggest that vocation-  2015) found that virtual reality job interview training was able to enhance the acceptance of job offers for treatment participants compared to control participants as well.

| Overall completeness and applicability of evidence
Despite the small number of studies included in our review, the rigorous search process confirms a relatively complete set of available studies on interventions' effects on employment for individuals with ASD. Our update of prior systematic reviews highlights that this area is still a growing field particularly when measuring employment outcomes as a result of vocational rehabilitation with individuals with ASD.
Because of the few studies in our review, and the relatively small sample sizes, we caution readers to not overly generalize the findings from our review.

| Quality of the evidence
In evaluating the overall quality of the evidence collected by the systematic review to support the use of specific interventions to promote the employment of individuals with autism, it should be noted that given the varying scope of the three studies as well as the heterogeneity of the population, claims of efficacy should be interpreted with caution. Additionally, although all three studies employed a RCT design, several risks of bias were identified for each.
Notably, performance and detection bias seem very likely for all three studies given that none used researcher or assessor blinding in their designs. Selection bias is likely for Smith et al. (2015) since randomization and group assignment procedures were not discussed. However, threats to selection bias were addressed in  by the use of specific randomization through a random number generator. It is uncertain whether attrition bias was a threat to the evidence of the studies. Participant attrition was discussed in Wehman et al. ( , 2017 as participants assigned to the control group-but not the treatment group-left the study; however, in

| Limitations and potential biases in the review process
There were several limitations in the review process. One restriction in our inclusion criteria was an employment outcome. Although there are many studies that evaluate the effectiveness of programs measuring more proximal outcomes such as interviewing skills, social interactions, or job-related skills, there were fewer studies that actually measured employment outcomes, which was perhaps more of a distal outcome in these studies. We tried to eliminate potential biases in the review process by identifying any conflicts of interest as none of the author team was responsible for designing or evaluating any of the included interventions in the review.

| Agreement and disagreement with other studies
Although many similar studies to those included in the review were  (2016) reported that roughly half of the participants achieved employment subsequently. However, it should be noted that the majority of research on Project SEARCH did not include specific ASD supports used by Wehman et al. ( , 2017. Specifically, only one descriptive article  and one retroactive record review  specified additional supports for individuals with ASD beyond the traditional Project SEARCH model.  . Other studies have examined the use of VR-JIT with other populations including individuals with posttraumatic stress disorder (Smith, Boteler Humm, et al., 2015), severe mental illness (Smith, Fleming, Wright, Jordan, et al., 2015), psychiatric disabilities (Smith, Ginger, Wright, Wright, Boteler Humm, et al., 2014), schizophrenia (Smith, Fleming, Wright, Roberts, et al., 2015), and substance abuse disorders (Smith et al., 2016). Additionally, virtual reality has been used in other studies for individuals with autism to teach skills related to employment and adult independence such as community navigation , driving safety (Bishop et al., 2017), and social competence (Stichter et al., 2014).
6 | AUTHORS' CONCLUSIONS 6.1 | Implications for practice and policy increased participants' likelihood of securing long-term employment (e.g., Christensen & Richardson, 2017;Kaehne, 2016). These findings also support previous correlational studies showing that individualized work experiences predict better outcomes in competitive, integrated employment (Haber et al., 2016). Additionally, while Smith, Fleming, Wright, Losh, et al. (2015) measured a novel approach to teaching a specific career readiness skill in using virtual reality to promote interview skills, this study also contributes to a more general body of research supporting the use of technology to teach skills and promote independence in a variety of employment  and school settings (Odom et al., 2015).

| Policy
In addition to their significance for practice, these studies also carry important policy implications that should be noted. First and foremost, while these three studies offer optimism in improving outcomes, the Transition Demonstration (YTD) Projects (Fraker et al., 2016;Ipsen et al., 2019). Although early studies published based on PROMISE and YTD did not meet inclusion criteria for this review, the scale of national effort to investigate this issue is noteworthy. Finally, given the focus of the studies included in this review on work-based learning (Wehman et al., , 2017 and career readiness skills (Smith, Fleming, Wright, Losh, et al., 2015), it should also be mentioned that these findings do align with recent policy changes brought about by the Workforce Innovation and Opportunity Act (WIOA) of 2014 that require state vocational rehabilitation agencies to use 15% of their annual budgets on promoting these two areas of pre-employment transition services to youth with disabilities, in addition to job exploration counseling, instruction in selfadvocacy, and counseling for opportunities in training and postsecondary education (WIOA, 2014).
We would also like to note that because our set of included studies were U.S.-based, that differences across settings and countries may exist with regard to practice and policy implications. What is this review about?

| Implications for research
The incidence of ASD is on the rise, yet individuals with ASD are gainfully employed at disproportionately lower rates than individuals without a disability. Employment interventions are vocational programs that provide training associated with access and maintenance of employment such as interviewing or vocational/social skills training.
This review looked at whether employment interventions and business-as-usual have different effects on the rates of employment.
What is the aim of this review?
This Campbell systematic review update examines the effects of employment interventions for people with autism spectrum disorders. The review summarizes evidence from three randomized controlled trials.

What studies are included?
This review uncovered three randomized studies from the USA that evaluate the effects of employment interventions for individuals with ASD. The studies spanned the period from 2014 to 2016.

Do interventions improve employment rates for individuals with ASD?
Yes. There is an overall improvement in employment rates for individuals with ASD that participate in vocational-related interventions.
What do the findings of this review mean?
The main policy-relevant findings include further consideration for how vocational rehabilitation is conducted among individuals with developmental disabilities such as ASD. Moreover, the relative paucity of empirical studies meeting inclusion criteria for this review points to an urgent need for greater funding for high-quality research and technical assistance to support the employment of individuals with ASD.
How up-to-date is this review?
The review authors searched for studies up to 2017.

Roles and responsibilities
• Content: Carlton Fong, Josh Taylor, and Kathleen M. Murphy.

DECLARATIONS OF INTEREST
We have no conflicts of interest to declare.

DIFFERENCES BETWEEN PROTOCOL AND REVIEW
The current review updated two prior systematic reviews that focused on employment-related interventions for individuals with ASD. One of the prior reviews (Westbrook et al., 2012a) and protocols (Westbrook et al., 2010) focused on adults, and the other review (Westbrook et al., 2013) and protocol (Westbrook et al., 2012b) on transition-age youth.
Thus, the updated review combined both protocols, deviating from the age restriction, to produce the current review.

PLANS FOR UPDATING THE REVIEW
We plan to update the review in 5 years in 2026. Carlton Fong will be responsible for updating the review.
(2017). Effects of an employer-based intervention on employment outcomes for youth with significant support needs due to autism. Autism, 21 (3)